Cow Milk Allergy
Cow’s milk allergy is an allergy to the milk proteins in cow's milk (and different from lactose intolerance). It is the most common food allergy in infants and young children in the UK. It usually affects 1 in 50 babies in the 1st Year of life. Most children outgrow cow's milk allergy by the age of three to five years. However, in some people cow's milk allergy may not be outgrown.
IgE mediated Cow’s Milk allergy (rapid onset allergic reactions to cow’s milk)
Symptoms occur immediately up to an hour after consuming cow’s milk or other dairy containing food. Symptoms include one of more of the following:
- Mild or moderate allergic reactions such itchy rash, redness or hives (nettle rash), swelling of the lips, face or eyes, stomach (tummy) pain, vomiting and diarrhoea.
- Sometimes (rarely) there can be severe allergic reactions include noisy breathing, breathing difficulties, tongue swelling, loss of consciousness or floppiness in babies or young children. These are concerning symptoms (anaphylaxis) and should always be treated as a medical emergency, requiring immediate treatment with adrenaline (epinephrine) and calling for an ambulance.
Diagnosis is based on the history of reaction to milk and additional allergy tests. Allergy tests (skin tests or blood tests) to cow’s milk are usually positive for rapid onset reactions. Treatment is the strict avoidance of milk and dairy food in child’s diet.
Non-IgE mediated Cow’s Milk allergy (delayed reactions to cow’s milk)
Delayed reactions usually occur after 2 or more hours up to 72 hours after consuming cow’s milk or other dairy foods. It can be difficult to spot the symptoms of food allergy – even for your doctor. The signs and symptoms of cow’s milk allergy can be mistaken for other common conditions seen in babies and infants.
Delayed allergy symptoms may include diarrhoea, constipation, reflux, vomiting, mucous/blood in stools, nausea, tummy pain, bloating, painful wind, eczema. Allergy tests to cow’s milk are usually negative for these reactions. Diagnosis usually involves excluding cow’s milk and other dairy foods from the diet for a trial period of two to four weeks to check for a clear improvement. A planned home challenge of cow’s milk and other dairy foods should occur to confirm diagnosis before longer term avoidance is advised.
Not all reactions to cow’s milk are due to allergy to cow’s milk protein
Lactose Intolerance
This is caused by the lack of the enzyme lactase, which helps to digest the milk sugar called lactose. Symptoms include diarrhoea, vomiting, stomach (abdominal) pain and gas (wind or bloating). This condition is uncomfortable but not dangerous and does not cause rashes or anaphylaxis. Allergy tests to cow’s milk are negative in people with lactose intolerance. Diagnosis is by temporary elimination of lactose and reintroduction. See our lactose intolerance page.
Management of cow’s milk allergy involves removing dairy foods from the diet
When should you worry?
12-18 months
12-18 MONTHS
Contact your health visitor or GP if your baby is 12-18 months and they…
- Have lost skills which they could do before
- Feel very stiff, for example:
- Hold their arms and legs in the same position, such as always pulling their arm to their chest, or always crossing their legs
- Find it difficult to change their position on their own
- You find it difficult to move your baby’s arms or legs, making it tricky to change their nappy or clothes
- Feel very floppy when they are awake
- Move their arms or legs in repetitive, jerky, or strange ways
- Use one side of their body more than the other, for example:
- Lean to the side when they sit
- Drag their leg or foot when crawling or walking
- Use one arm to pull to stand more than the other
- Rarely use one of their arms to pick up toys, or eat and drink
- Finds it hard to stand or walk, for example:
- Can’t pull to stand
- Fall over a lot when standing still
- Doesn’t cruise (walk while holding on to furniture)
- Walk on their tiptoes a lot
18-24 months
18-24 MONTHS
Contact your health visitor or GP if your baby is 18-24 months and they…
- Have lost skills which they could do before
- Feel very stiff, for example:
- Hold their arms and legs in the same position, such as always pulling their arm to their chest, or always crossing their legs
- Find it difficult to change their position on their own
- You find it difficult to move your baby’s arms or legs, making it tricky to change their nappy or clothes
- Feel very floppy when they are awake
- Move their arms or legs in repetitive, jerky, or strange ways
- Use one side of their body more than the other, for example:
- Lean to the side when they sit
- Drag their leg or foot when crawling or walking
- Use one arm to pull to stand more than the other
- Rarely use one of their arms to pick up toys, or eat and drink
- Find it hard to balance when standing still, or fall over a lot
- Can’t walk by themselves
- Walk on their tiptoes a lot
- Are suddenly unsteady when walking
2 years
2 YEARS
Contact your health visitor or GP if your baby is 2 years and they…
- Have lost skills which they could do before
- Feel very stiff, for example:
- Hold their arms and legs in the same position, such as always pulling their arm to their chest, or always crossing their legs
- Find it difficult to change their position on their own
- You find it difficult to move your child’s arms or legs, making it tricky to change their nappy or clothes
- Feel very floppy when awake
- Move their arms or legs in repetitive, jerky, or strange ways
- Use one side of their body more than the other, for example:
- Lean to the side when they sit
- Drag one leg or foot behind them when crawling or walking
- Rarely use one of their arms to play, eat and drink
- Find it hard to balance when standing still or fall over a lot
- Can’t walk by themselves
- Mostly walk on their tiptoes
- Are suddenly unsteady when walking
- Haven’t started to run
- Move from laying down or sitting to standing by using their hands to push off the ground, and “walk” their hands up their legs until they are standing
3 years
3 YEARS
Contact your health visitor or GP if your baby is 3 years and they…
- Have lost skills which they could do before
- Feel very stiff, for example:
- Hold their arms and legs in the same position, such as always pulling their arm to their chest, or always crossing their legs
- Find it difficult to change their position on their own
- You find it difficult to move your child’s arms or legs, making it tricky to change their clothes
- Feel very floppy when awake
- Move their arms or legs in repetitive, jerky, or strange ways
- Use one side of their body more than the other, for example:
- Lean to the side when they sit
- Drag one leg or foot behind them when walking
- Rarely uses one of their arms to play, eat and drink
- Find it hard to balance when standing still or fall over a lot
- Can’t walk by themselves
- Mostly walk on their tiptoes
- Are suddenly unsteady when walking
- Have not started to jump or run
- Move from laying down or sitting to standing by using their hands to push off the ground, and “walk” their hands up their legs until they are standing
4 years
4 YEARS
Contact your health visitor or GP if your baby is 4 years and they…
- Have lost skills which they could do before
- Feel very stiff, for example:
- Hold their arms and legs in the same position, such as always pulling their arm to their chest, or always crossing their legs
- Find it difficult to change their position on their own
- Find it tricky to change their clothes
- Feel very floppy when awake
- Move their arms or legs in repetitive, jerky, or strange ways
- Use one side of their body more than the other, for example:
- Lean to the side when they sit
- Drag one leg or foot behind them when walking
- Rarely use one of their arms to play, eat and drink
- Find it hard to balance when standing still
- Suddenly become unsteady when walking
- Find it hard going upstairs or uphill
- Trip or fall a lot
- Walk on tiptoes most of the time
- Feel pain in their arms or legs
- Move from laying down or sitting on the floor to standing by using their hands to push off the ground, and “walk” their hands up their legs until they are standing.
5 years
5 YEARS
Contact your health visitor or GP if your baby is 5 years and they…
- Have lost skills which they could do before
- Feel very stiff, for example:
- Hold their arms and legs in the same position, such as always pulling their arm to their chest, or always crossing their legs
- Find it difficult to change their position on their own
- Find it tricky to change their clothes
- Feel very floppy when awake
- Move their arms or legs in repetitive, jerky, or strange ways
- Use one side of their body more than the other, for example:
- Lean to the side when they sit
- Drag one leg or foot behind them when walking
- Rarely uses one of their arms to play, eat and drink
- Find it hard to balance, or trip or fall a lot
- Persistently walk on tiptoes
- Suddenly become unsteady when walking
- Feel pain in their arms or legs
- Move from laying or sitting on the floor to standing by using their hands to push off the ground, and “walk” their hands up their legs until they are standing.
15 months
Your Child By Fifteen Months
Social/Emotional Milestones
- Copies other children while playing, like taking toys out of a container when another child does
- Shows you an object she likes
- Claps when excited
- Hugs stuffed doll or other toy
- Shows you affection (hugs, cuddles, or kisses you)
Language/Communication Milestones
- Tries to say one or two words besides “mama” or “dada,” like “ba” for ball or “da” for dog
- Looks at a familiar object when you name it
- Follows directions given with both a gesture and words. For example, he gives you a toy when you hold out your hand and say, “Give me the toy.”
- Points to ask for something or to get help
Cognitive Milestones (learning, thinking, problem-solving)
- Tries to use things the right way, like a phone, cup, or book
- Stacks at least two small objects, like blocks
Movement/Physical Development Milestones
- Takes a few steps on his own
- Uses fingers to feed herself some food
18 months
Your Child By Eighteen Months
Social/Emotional Milestones
- Moves away from you, but looks to make sure you are close by
- Points to show you something interesting
- Puts hands out for you to wash them
- Looks at a few pages in a book with you
- Helps you dress him by pushing arm through sleeve or lifting up foot
Language/Communication Milestones
- Tries to say three or more words besides “mama” or “dada”
- Follows one-step directions without any gestures, like giving you the toy when you say, “Give it to me.”
Cognitive Milestones (learning, thinking, problem-solving)
- Copies you doing chores, like sweeping with a broom
- Plays with toys in a simple way, like pushing a toy car
Movement/Physical Development Milestones
- Walks without holding on to anyone or anything
- Scribbles
- Drinks from a cup without a lid and may spill sometimes
- Feeds himself with his fingers
- Tries to use a spoon
- Climbs on and off a couch or chair without help
2 years
Your Child By Two Years
Social/Emotional Milestones
- Notices when others are hurt or upset, like pausing or looking sad when someone is crying
- Looks at your face to see how to react in a new situation
Language/Communication Milestones
- Points to things in a book when you ask, like “Where is the bear?”
- Says at least two words together, like “More milk.”
- Points to at least two body parts when you ask him to show you
- Uses more gestures than just waving and pointing, like blowing a kiss or nodding yes
Cognitive Milestones (learning, thinking, problem-solving)
- Holds something in one hand while using the other hand; for example, holding a container and taking the lid off
- Tries to use switches, knobs, or buttons on a toy
- Plays with more than one toy at the same time, like putting toy food on a toy plate
Movement/Physical Development Milestones
- Kicks a ball
- Runs
- Walks (not climbs) up a few stairs with or without help
- Eats with a spoon
2.5 years
Your Child By Thirty Months
Social/Emotional Milestones
- Plays next to other children and sometimes plays with them
- Shows you what she can do by saying, “Look at me!”
- Follows simple routines when told, like helping to pick up toys when you say, “It’s clean-up time.”
Language/Communication Milestones
- Says about 50 words
- Says two or more words together, with one action word, like “Doggie run”
- Names things in a book when you point and ask, “What is this?”
- Says words like “I,” “me,” or “we”
Cognitive Milestones (learning, thinking, problem-solving)
- Uses things to pretend, like feeding a block to a doll as if it were food
- Shows simple problem-solving skills, like standing on a small stool to reach something
- Follows two-step instructions like “Put the toy down and close the door.”
- Shows he knows at least one color, like pointing to a red crayon when you ask, “Which one is red?”
Movement/Physical Development Milestones
- Uses hands to twist things, like turning doorknobs or unscrewing lids
- Takes some clothes off by himself, like loose pants or an open jacket
- Jumps off the ground with both feet
- Turns book pages, one at a time, when you read to her
3 years
Your Child By Three Years
Social/Emotional Milestones
- Calms down within 10 minutes after you leave her, like at a childcare drop off
- Notices other children and joins them to play
Language/Communication Milestones
- Talks with you in conversation using at least two back-and-forth exchanges
- Asks “who,” “what,” “where,” or “why” questions, like “Where is mommy/daddy?”
- Says what action is happening in a picture or book when asked, like “running,” “eating,” or “playing”
- Says first name, when asked
- Talks well enough for others to understand, most of the time
Cognitive Milestones (learning, thinking, problem-solving)
- Draws a circle, when you show him how
- Avoids touching hot objects, like a stove, when you warn her
Movement/Physical Development Milestones
- Strings items together, like large beads or macaroni
- Puts on some clothes by himself, like loose pants or a jacket
- Uses a fork
4 years
Your Child By Four Years
Social/Emotional Milestones
- Pretends to be something else during play (teacher, superhero, dog)
- Asks to go play with children if none are around, like “Can I play with Alex?”
- Comforts others who are hurt or sad, like hugging a crying friend
- Avoids danger, like not jumping from tall heights at the playground
- Likes to be a “helper”
- Changes behavior based on where she is (place of worship, library, playground)
Language/Communication Milestones
- Says sentences with four or more words
- Says some words from a song, story, or nursery rhyme
- Talks about at least one thing that happened during her day, like “I played soccer.”
- Answers simple questions like “What is a coat for?” or “What is a crayon for?”
Cognitive Milestones (learning, thinking, problem-solving)
- Names a few colors of items
- Tells what comes next in a well-known story
- Draws a person with three or more body parts
Movement/Physical Development Milestones
- Catches a large ball most of the time
- Serves herself food or pours water, with adult supervision
- Unbuttons some buttons
- Holds crayon or pencil between fingers and thumb (not a fist)
5 years
Your Child By Five Years
Social/Emotional Milestones
- Follows rules or takes turns when playing games with other children
- Sings, dances, or acts for you
- Does simple chores at home, like matching socks or clearing the table after eating
Language/Communication Milestones
- Tells a story she heard or made up with at least two events. For example, a cat was stuck in a tree and a firefighter saved it
- Answers simple questions about a book or story after you read or tell it to him
- Keeps a conversation going with more than three back-and-forth exchanges
- Uses or recognizes simple rhymes (bat-cat, ball-tall)
Cognitive Milestones (learning, thinking, problem-solving)
- Counts to 10
- Names some numbers between 1 and 5 when you point to them
- Uses words about time, like “yesterday,” “tomorrow,” “morning,” or “night”
- Pays attention for 5 to 10 minutes during activities. For example, during story time or making arts and crafts (screen time does not count)
- Writes some letters in her name
- Names some letters when you point to them
Movement/Physical Development Milestones
- Buttons some buttons
- Hops on one foot
Advice and Guidance
Home milk challenge to confirm cow's milk protein allergy
All standard infant formula (eg SMA, Comfort milk, Cow & Gate, Aptamil) contains cow’s milk protein.
For children with mild to moderate delayed symptoms
It is important to try your baby with milk now. This is to make sure that any improvement in their symptoms is due to cutting out milk (and they have a cow's milk protein allergy) rather than for any other reason.
- Do NOT start this challenge if your child has had either immediate symptoms (within an hour of eating/drinking dairy) or a positive blood or skin test (specific IgE or Skin Prick Test) to cow's milk.
- Do NOT start this challenge if your child is unwell e.g.
- Has a cold or any other lung infections or breathing problems
- Any tummy/bowel problems e.g. tummy ache or loose nappies
- Any 'teething' signs that are upsetting your child
- Atopic dermatitis (eczema) has flared up
- Do NOT start this challenge if your child is having any medication which may upset their tummy, e.g. antibiotics
- Do NOT try any other new foods during this challenge
Try to write down what your child eats and drinks during the challenge. Also note any symptoms e.g. sickness, loose nappies, rashes or any other changes in their atopic dermatitis.
Home challenge for a formula fed baby (those taking formula with or without some breastfeeds):
Follow the advice in the table below: each day, increase the amount of cow's milk formula given in baby's FIRST bottle of the day - (use the scoop provided in each).
A Practical Example of a Reintroduction in a Formula Fed Child
If you have not seen any symptoms in your child by day 7 (when you have completely replaced one bottle a day with cow's milk formula) you can give your child cow's milk formula in all bottles.
Home challenge for an exclusively breastfed baby:
Simply start eating dairy products to the same levels as before starting on the diet.
All babies:
If you see any obvious symptoms e.g. sickness, tummy pains, a rash, itching, STOP the challenge. Go back to the previous formula your baby was taking or to a milk free diet if you are breastfeeding, and inform your GP.
If no symptoms occurs within 2 weeks of your child having more than 200ml (almost 7fl.oz.) of cow's milk formula per day, your child does not have cow's milk allergy.
Milk free diet for breastfeeding mums
This dietary advice gives general information to help you make the recommended changes to your diet while you are breast feeding and while your child requires a cow’s milk free diet. If you need more detailed advice, please ask your doctor to refer you to a Dietitian for advice on your diet.
Breast feeding is best for your baby. Unfortunately, the cow’s milk protein you eat can pass through to your breast milk. This means that your baby can be exposed to cow’s milk protein from your breast milk if you ingest cow’s milk and cow’s milk products.
Occasionally, breast fed babies can react to milk proteins transferred in breast milk from the mother’s diet. If your baby reacts to cow's milk proteins in your breast milk, you will be advised to avoid milk (dairy) whilst breastfeeding. This is usually done as a trial for between 4 to 6 weeks to see if your baby’s symptoms improve. If they do not, and you were following the diet strictly, you can return to your normal diet. If your baby's symptoms improve whilst you are on a cow's milk free diet, you would be asked to reintroduce cow's milk back into diet after 4-6 weeks (Home challenge) to check for any return of symptoms. Should there be return of symptoms on home challenge, non-IgE milk allergy is confirmed.
If your baby develops symptoms only on introduction of cow's milk in weaning/cow's milk containing feed (infant formulas), we encourage you to return to full breast feeding, and start milk free weaning. It is important to remember that if your baby does not have any symptoms on breast feed, while you (mother) are consuming cow's milk, you can continue to consume cow's milk containing foods in your diet, and initiate cow’s milk free weaning.
A small proportion of milk allergic children may also react to soya proteins in which case this also needs to be avoided in maternal milk.
If you have any other allergies or medical conditions, please seek further advice.
It is important for you to have a milk free diet- please check food labels and avoid products containing “Milk”.
Suitable alternatives to cow's milk are Calcium enriched soya milk, oat milk, nut milks (cashew, almond, hazelnuts), pea, coconut, hemp milk etc.
Ingredients to watch out for on labels:
Milk and milk products will be indicated and 'milk' in bold on the ingredient list, check the labels.
Calcium and Vitamin D
- When breast feeding, you require approximately 1250 mg of calcium per day. This can be difficult to obtain from your diet when you are avoiding cow’s milk and cow’s milk products.
- To achieve a sufficient intake it is important that you try to use a calcium enriched cow’s milk substitute (for example soya drink, oat drink, rice drink, nut drink, hemp drink) and include non-dairy sources of calcium in your diet.
- Other mammalian milks such as goat milk and sheep milk and their products contain proteins similar to cow’s milk and should also be avoided.
- It may also be advisable for you to take a calcium supplement (1000 mg/day), please discuss this with your doctor.
- The Department of Health recommends that all breast-feeding mums take a 10µg Vitamin D supplement which can be obtained from pharmacies or health food shops.
Calcium content of foods
Example of how to meet 1250 mg Calcium per day
Milk free diet for babies
Why a milk free diet?
Around 3% of children develop non-IgE Cow's Milk Protein Allergy (CMPA). In most cases a strict cow's milk free diet is needed to manage the symptoms of the allergy. This information will help you avoid cow's milk whilst making sure your child gets all the nutrition they need to grow and develop.
Which milk should be excluded?
Avoidance needs to include fresh, UHT, sterilised and dried cow’s milk. The diet should be free of cow's milk protein (casein and whey) and milk sugar (lactose). Other mammalian milks are not suitable alternatives to cow's milk as their protein structure is similar and may still cause an allergic response. Therefore, do not use milks such as goats, sheep, camel and buffalo milk.
Replacing cow's milk
Cow’s Milk is an important source of nutrition for babies and children. If you breast feed your baby, continue to breast feed, while following a milk free diet. If your baby is taking an infant formula, it needs to be a milk free formula.
Important to remember - occasionally, breast fed babies can react to milk proteins transferred in breast milk from the mother’s diet. If your baby develops symptoms only on introduction of cow's milk in weaning/cow's milk containing feed (infant formulas), we encourage you to return to full breast feeding, and continue with milk free weaning. It is important to remember that if your baby does not have any symptoms on breast feed, while you (mother) are consuming cow's milk, you can continue to consume cow's milk containing foods in your diet.
Suitable infant formula free of cow's milk proteins
Your baby may have been prescribed a formula such a Alimentum, Althera, Nutramigen LGG, Aptamil Pepti (or more rarely Alfamino, Puramino, Neocate or Elecare). They should continue this until 12 months or as advised by your Health Care Professional.
Most babies aged 6-12 months need approximately 600ml (20oz) each day to ensure they are meeting their nutritional needs, especially Calcium.
Over 1 year this amount reduces to approximately 350ml (12oz).. Check with your Health Visitor or Dietitian if you have concerns about your child’s calcium needs.
Other alternatives to cow's milk for cooking
A variety of plant based calcium enriched cow's milk substitutes fortified with calcium are available to buy from most supermarkets. They can be used in cooking from six months of age or as a main drink after one year old.
Examples include:
Oat milk
Soya milk – soya milk should not be given to babies under 6 months of age. Soya can be introduced as part of weaning in the form of soya yogurts/pudding or cooking after 6 months if soya is safe for your child. Some children with non-IgE milk allergy may also be allergic to soya. Please be guided by your dietitian. Soya milk can be used as a main drink after 1 year of age.
Nut milk alternatives (almond, coconut, cashew, hazelnut),
Hemp milk/pea milk/coconut milk
Rice milk should not be given to children under four and a half years old. This is due to concerns about arsenic content.
Babies with milk allergies can and should have nuts (in the form of nut butters) introduced into their diets to reduce the chance of allergies in later life. (as long as they have not had any allergic symptoms)
Always choose a milk alternative that is fortified or enriched with calcium - they should provide at least 120 mg of calcium/100mls. Organic versions do not usually have calcium added - check the label.
Foods to avoid
Look for the list of ingredients printed on the package and avoid foods which have 'milk' in bold on the label. When eating out, food outlets need to provide you with allergy information by law, so always ask.
Check with your pharmacist about tablets or medicines which may contain milk protein and/or lactose.
Introducing solids (weaning)
Starting solids for a baby who has Cow's Milk Allergy should be the same as for a non-allergic baby, however you must not give any foods that contain cow's milk or dairy products (example yogurt, fromage frais, cheese, cream or butter). You should aim to start solid foods at around six months, but not before four months (17 weeks). If your baby is premature, check with your dietitian about the best time to start. For general information on introducing solids, check the NHS choice website page your baby's first solid foods - NHS (www.nhs.uk)
Adapting recipes
Many recipes can be adapted by using your chosen supermarket milk alternative. Use a milk free margarine instead of butter, milk alternatives in place of milk, and vegan cheese in place of cheese. Try making up batches of milk free meals/puddings and freezing them.
What about calcium?
Calcium is needed for strong teeth and healthy bones. It is important that breast feeding mum's and children on a cow's milk free diet our meeting that calcium requirement. The following table shows how much is needed for each age group:
Babies under 1 year of age – 525 mg calcium per day
1-3 year olds- 350 mg calcium per day
Breast feeding mothers – 1250 mg calcium per day
Sources of Calcium (portion size are not necessarily baby size!)
What about Vitamin D?
Vitamin D is needed by the body to absorb calcium/regulate calcium and phosphate in the body. Our body creates Vitamin D from direct sunlight on the skin when outdoors. Vitamin D is also found in a small number of foods. Vitamin D is only found in a few foods so a supplement is recommended for everyone
A supplement containing Vitamins A, C and D can be given from 6 months, (Healthy Start Vitamins) (Department of Health advice). It is advised that breastfed babies take a vitamin D supplement from birth.
Supplements are available to purchase in pharmacies and supermarkets, or may be available online.
NB micrograms (mcg) can also be written as μg.
Formula feeding a baby with cow's milk protein allergy.
Milk free weaning for babies with cow’s milk protein allergy (video 5)
Milk and soya free diets for babies
Why a milk and soya free diet?
Around 3% of children develop non-IgE Cow’s Milk Protein Allergy. Some children who are allergic to cow's milk protein are also allergic to soya protein so this may need to be excluded from the diet too. This information will help you avoid cow's milk protein and soya protein whilst making sure your baby gets all the nutrition they need to grow and develop
Cow's milk allergy in children | Health topics A to Z | CKS | NICE
Which milks should be excluded?
Avoidance needs to include fresh, UHT, sterilised and dried cow’s milk and soya milk options. The diet should be free of cow's milk protein (casein and whey), soya protein and milk sugar (lactose). Other mammalian milks are not suitable alternatives to cow's milk as their protein structure is similar and may still cause an allergic response -do not use milks such as goats, sheep, camel and buffalo milk.
Replacing cow's milk and soya
Cow’s Milk is an important source of nutrition for babies and children. If you breast feed your baby, continue to breast feed your little one, while following a milk and soya free diet. If your baby is taking an infant formula, it needs to be a milk/soya free formula.
Important to remember- Occasionally, breast fed babies can react to milk proteins/soya proteins transferred in breast milk from the mother’s diet. It is important to remember that if your baby does not have any symptoms on breast feed, you can continue on normal diet without restrictions
Suitable infant formula free of cow's milk and soya proteins
Your baby may have been prescribed a formula such a Alimentum, Althera, Nutramigen LGG, Aptamil Pepti (or more rarely Alfamino, Puramino, Neocate or Elecare). They should continue this until 12 months or as advised by your Health Care Professional.
Most babies aged 6-12 months need approximately 600ml (20oz) each day to ensure they are meeting their nutritional needs, especially calcium.
Over 1 year this amount reduces to approximately 350ml (12oz). Check with your Health Visitor or Dietitian if you have concerns about your child’s calcium needs.
Other alternatives to cow's milk and soya milk for cooking
Alternatives to milk that are fortified with calcium are available to buy from most supermarkets. They can be used in cooking from six months of age or as a main drink after one year old.
Examples include:
- Nut milk alternatives (almond, coconut, cashew, hazelnut),
- Oat milk
- Hemp, pea, coconut milk
Rice milk should not be given to children under four and half years old.
Always choose a milk alternative that is fortified or enriched with calcium - they should provide at least 120 mg of calcium/100mls. Organic versions do not usually have calcium added - check the label.
Foods to avoid
Look for the list of ingredients printed on the package and avoid foods which have 'milk' and/or 'soya' in bold on the label. When eating out, food outlets need to provide you with allergy information by law, so always ask.
Check with your pharmacist about tablets or medicines which may contain milk or soya proteins and/or lactose.
Introducing solids (weaning)
Starting solids for a baby who has non-IgE cow's milk and soya protein allergy should be the same as for a non-allergic baby, however you must not give any foods that contain cow's milk or soya products. Aim to start around six months, but not before four months (17 weeks). For general information on introducing solids, check the NHS choice website page - your baby's first solid foods - NHS (www.nhs.uk)
Adapting recipes
Many recipes can be adapted by using your chosen supermarket milk alternative. Use a milk and soya free margarine instead of butter and milk alternatives in place of milk. Try making up batches of milk and soya free meals/puddings and freezing them
Calcium and Vitamin D
For further information please see our what about calcium section on milk free diet for babies above for further information regarding calcium and vitamin D.
The Milk Ladder
All standard infant formula (eg SMA, Comfort milk, Cow & Gate, Aptamil) contains cow’s milk protein.
An assessment of your child’s allergy, medical history and/or results indicate that it is time to see if they have outgrown their food allergy. This can be done by adding milk into the diet gradually at home.
Milk is introduced into the diet by following a ‘milk ladder’ where each food contains increasing levels of milk protein. It is important to start with well-cooked/processed milk first before progressing to ‘uncooked’ dairy products. This ‘milk ladder’ is based on scientific research.
Remember, these foods are part of a mixed diet and are not expected to be a significant part of the child’s diet. The Milk Ladder should only be used:
- In children with mild to moderate delayed (non-IgE) cow’s milk protein allergy symptoms (watch the film cow’s milk allergy explained if you are unsure of the type of reaction your baby has had)
- Baby/child has been milk free for 6 months and can manage to eat foods on the milk ladder
- Your child is well
Do NOT start this challenge if:
- Your child has had either immediate symptoms (within an hour of eating/drinking dairy) or a positive blood or skin test (specific IgE or Skin Prick Test) to cow's milk
- Your child is unwell, e.g. cold or chest infection etc
- Your child has any tummy/bowel problems e.g. tummy ache or loose nappies
- Your child has any ‘teething’ signs that are upsetting your child
- Atopic dermatitis (eczema) has flared up
- Your child is having any medication which may upset their tummy, e.g. antibiotics.
Throughout the challenge, it is useful to keep a record of the foods tried/the amounts eaten and any reaction (including how long after the food was eaten did the reaction occur). Each of the foods listed contain progressively more milk protein. The time spent in each step will vary for one child to another depending on how they presented. Each step will take at least 3 days to a week but it is fine to go slower than this if needed.
The Milk Ladder
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The lower steps of the milk ladder are designed to be used with homemade recipes to ensure that each step has the appropriate milk intake. You can ask your health professional (dietician) for further guidance on the steps or for recipes if needed.
Step 1:
Start with ¼ of biscuit on the first morning, if no symptoms, give half a biscuit the next day and gradually increase till they can have 3 biscuits a day without any problems. If using store-bought biscuits rather than homemade look for a biscuit that contains milk powder as one of its ingredients.
Step 2:
Start with ¼ to ½ a muffin and build up to one muffin.
Step 3:
Start with ¼ to ½ a pancake and build up to one. If using store-bought pancakes, they should contain milk protein as one of its ingredients. (Pancakes contain less milk than muffins but are cooked for a shorter time).
Step 4:
Start with a thin slice of hard cheese such as cheddar or parmesan. Increase the amount gradually until your child is eating 15g baked cheese e.g. on a pizza or lasagne.
Step 5:
Start with one small teaspoon of yoghurt and increase daily until eating 125 mls (4.5 oz) yoghurt. Once your child tolerates yogurt you can include butter, chocolate buttons and cream cheese. Once your child tolerates yoghurt, butter, spread, chocolate buttons, fromage frais, petit filous (be careful of the sugar content), you can introduce softer cheese like cream cheese and camembert/brie –remember to use pasteurised soft cheese for children.
Step 6:
Pasteurised milk (or suitable infant formula). Introduce 100ml (3.5 oz) pasteurised cow’s milk or infant formula (powder) and mix with current milk replacement. Build up to 200 mls. (7 fl oz.) If this is tolerated switch all current milk replacements to pasteurised milk or suitable infant formula. UHT and sterilised milk will be tolerated as well.
Some children may be able to tolerate a certain amount of cow’s milk in their diet If they have more than the amount that they are able to tolerate then they may develop symptoms (up to 48 hours later). If this is the case it is sensible to include dairy products and cow’s milk up to the amount they can tolerate while remaining symptom free.
If the food at any step of the ladder is tolerated, your child should continue to consume this (as well as all foods in the previous steps) and then try the food in the next agreed step.
If the child does not tolerate the food in a particular step, simply go back to the previous step. Re-try again in 2-3 months to check if able to progress.
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